Table 2 Clarifying the problem underpinning high rates of medication error

• How did the problem come to attention and has this process influenced the prospect of it being addressed?

   ◊ The problem of medical error may come to attention through a focusing event (e.g. a child dies because a doctor prescribes the wrong drug dosage), a change in an indicator (e.g. there is a dramatic increase in the number of reported errors in a given month) or feedback from the operation of current policies and programmes (e.g. an evaluation report identifies more types of medication errors than have been routinely measured)

   ◊ An evaluation report may identify that one possible factor contributing to a problem is the lack of clear boundaries of the scope of practice between doctors, nurses and pharmacists, which makes accountability for prescribing, dispensing, administration and chart documentation unclear

   ◊ The same report may propose that the problem be turned into a statement of purpose that can be used to engage a diverse array of stakeholders. For example, policymakers may prefer to speak about how their country will become a leader in patient safety, rather than referring to current patient safety problems

• What indicators can be used or collected to establish the magnitude of the problem and to measure progress in addressing it?

   ◊ Policymakers may identify that no indicators are currently being measured accurately at the national level but that they are interested in starting to accurately measure both the number of medication error reports per quarter and the number of ‘near misses’ per quarter. Collecting such data would allow them to set a target level for the indicator

• What comparisons can be made in order to establish the magnitude of the problem and to measure progress in addressing it?

   ◊ Policymakers may identify that they would like to make four types of comparisons:

–        Comparisons over time within the country

–        Comparisons to other appropriate comparator countries

–        Comparisons against a target to be set as part of a national patient safety strategy

–        Comparisons against what a national consumer association has said it would like to see

   ◊ Ideally a search for administrative database studies or community surveys would allow the policymakers to identify at least some existing research evidence and allow them to make immediate comparisons

• How can a problem be framed (or described) in a way that will motivate different groups?

   ◊ Policymakers may find that:

–        Pharmacists respond to the language used to describe a medication error

–        Consumer groups respond to a stated purpose of achieving, for example, a 50% reduction in medication errors

–        Regulators engage when the lack of clear boundaries between the scope of practice of healthcare providers is discussed as an important feature of the problem

–        Hospital staff may respond positively when told of a plan to collect an indicator that identifies under-reporting in a way does not penalise units or departments who support full disclosure

–        Hospital executives may engage most fully when comparisons are made among their facilities

   ◊ Ideally a search for qualitative studies would allow the policymakers to grasp the different meanings that different groups attach to a problem